CM Back & Spine Flashcards
(50 cards)
1
Q
Number of Americans who have back pain at any given time
A
50 million
2
Q
Lifetime chance of experiencing back pain
A
80%
3
Q
Most common cause of disability under age 45
A
Back pain
4
Q
Back pain
A
- Most expensive health care costs in the 20-50 year age group
- Est costs of treating back pain is $50 billion/yr
5
Q
Cervical spine
A
C1-C7
Neck problems cause neck pain and/or arm pain
6
Q
Thoracic spine
A
T1-T12
These vertebrae attach to the ribs and sternum giving this area greater stability, therefore less problems
7
Q
Lumbar spine
A
L1-L5
This section bears the majority of the body’s weight, therefore this area is associated w/the most spine related problems
8
Q
Sacral spine
A
The sacrum is composed of 5 bony segments fused together
4 bones extend down from the sacrum to form the coccyx
9
Q
Intervertebral Discs
A
Made up of annulus fibrosus and nucleus pulposus
- Spinal discs are located in between each of the vertebral bodies
- Each disc named from which two vertebral bodies it lies between
- Discs are fibrocartilage cushions serving as the spine’s “shock absorbers”
- Discs allow for some vertebral motion: includes flexion/extension as well as some rotation
10
Q
Neuroanatomy
A
Dermatomes-you should know these; very important for physical exam, consider carrying a pocket guide
**Document specific motor and sensory nerves, both normal and abnormal
11
Q
Cervical motor nerves
A
C4: trapezius, rhomboid C5: deltoid, biceps C6: wrist extensors C7: triceps, wrist flexors C8: finger flexors T1: intrinsics
12
Q
Lumber motor nerves
A
L1: iliopsoas L2: iliopsoas L3: quadraceps L4: tibialis anterior L5: EHL, gluteus medius S1: gastroc, soleus, peronei S2-5: rectal examination
13
Q
Cervical reflexes
A
C5: Biceps
C6: Brachioradialis
C7: Triceps
14
Q
Lumbar reflexes
A
L4: Patellar
S1: Achilles
15
Q
Muscle Strength Testing
A
0/5 No function 1/5 Minimal contraction 2/5 Moves w/gravity eliminated 3/5 Resists gravity 4/5 Moves against gravity 5/5 Normal strenght (Less than 5/5 is abnormal)
16
Q
Spondylogenic Causes of Back pain
A
Disc degeneration Spondylolisthesis Fractures Inflammatory Infection Tumor
17
Q
Non Spondylogenic Causes of Back pain
A
Vasculogenic
Viscerogenic
Neurogenic
18
Q
Pathology of Disc Degeneration
A
- “Dehydration”
- Nucleus pulposus: desiccated, can lead to dehydration
- Annulus fibrosis: fissures, can lead to dehydration
19
Q
Aggravating Factors: Symptomatic Disc Degeneration
A
Repetitive bending, lifting, twisting Vibration (ex truck drivers) Smoking Osteoporosis Genetic or Occupational Anxiety/stress/depressed
20
Q
RED FLAGS of Back Pain
A
Back pain in the elderly
Back pain in children w/out hx of trauma
21
Q
Back Pain in Elderly
A
- Compression Fx, spontaneous
- Tumor
- Infection
22
Q
Back Pain in Children
A
- Rare compared to adults
- Must be evaluated
- Painful scoliosis is a red flag (Scoliosis is typically not painful)
23
Q
Radiculopathy
A
- Characterized by pain which seems to radiate from the spine to extend outward to cause sxs away from the source
- Common problem that results when a nerve root is compressed or irritated, or bone spurs present
- Pts may complain of pain, numbness, tingling, or weakness (can be intermittent or constant-indicates worse problem
- *Decreased sensation does NOT equal weakness
24
Q
Acute low back sprain/strain
A
- Occurs when the muscles surrounding the spine are asked to stretch too far, lift too much weight, or move in such a way that they sustain very small tears
- Because of the tearing of the muscles, small microscopic bleeding occurs which in turn results in pain and muscle spasm
- AP and Lateral xrays if warranted (pt tenderness)
- Majority managed w/course of NSAIDs, a very brief period of rest, and then a gradual return to full activity
- Always consider weight loss, PT
25
Herniated Disk
AKA slipped disc, bulging disc, disc protrusion
- Most herniations occur in the age group 30-40
- Usually fast onset
- Usually not related to trauma or injury
- Pt typically describes "sharp, shooting" pain
26
Most common location of a herniated disc
L4-5 or L5-S1
27
Herniated Disc Dx
- Complete H&P, emphasis on neurologic exam
- Deep tendon reflexes
- Specific motor group testing
- Sensory deficit to specific dermatome patterns: light touch and pin prick
- Nerve root tension sigh: straight leg raise (pain thru sciatic, mimics sxs)
- Severe pain and/or neurologic deficit warrants MRI,MRI myelogram (warning for renal problems); CT, EMG (nerve conduction study)
28
Herniated Disc Tx
- 85-90% of first time disc herniations will resolve within 3 months of onset of sxs w/o any tx modalities
- Initially tx w/short term bed rest w/gradual return to normal activities
- Other conservative modalities include PT, chiropractic, acupuncture, pilates, yoga
- Surgical tx is warranted when all conservative measures fail or neurologic deficit is present
29
Spondylosis:
Degenerative process of the spine
| "Arthritis of the spine"
30
Spondylolysis:
Defect that occurs in the posterior aspect of the spine known as the pars interarticularis
- Essentially a stress fracture in the vertebral body
- Defect=lysis=fracture
31
Spondylolisthesis:
Occurs when one vertebra slips foreward on another resulting in a Scotty Dog Fx
- A fracture w/slippage
- Spondylolysis causes spondylolisthesis
- Listhesis=Slippage
32
Spondylolysis
- Essentially a stress fracture in the vertebral body
- Common cause of low back pain in children
- 5% of the general population has this condition w/the vast majority being asx
- MC in football linemen and young gymnasts
33
Spondylolysis Dx
- Typical sx include low back pain esp when involved in activities that place the spine in an extended position
- Complete H&P (remember back pain in the pediatric population is a RED FLAG)
- Dx is made w/imaging studies including plain flim xrays (oblique views), MRI, CT, Bone scan
34
Spondylolysis Tx
- Initial tx is rest and possible bracing w/hopes of the fracture healing
- Progress into exercise w/emphasis in trunk and abdominal strengthening
- Return to normal activity
35
Spondylolisthesis
- Occurs when one vertebrae slips forward on another
- Produces a gradual deformity of the spine and narrowing of the vertebral canal
- Known as the "Scotty Dog" fracture (Dog's "neck" is broken)
- A positive Scotty Dog sign is a fracture or defect thru the pars interarticularis
36
Spondylolisthesis Notes
- Spondylolysis and spondylolisthesis involve a defect in the pars interarticularis
- Sometimes there is a positive scotty dog sign in pts w/spondylolysis and you can see the pars defect or fracture
- It is usually very difficult to pick up on a positive Scotty Dog sign in spondylolysis (esp if it is minor and/or the injury is recent) on xray due to bowel gas, other structures overlying this subtle finding
- Additionally, slippage or spondylolisthesis isn't present
37
Vertebral Compression Fx
- Fracture of the vertebral body itself
- Causes may include osteoporosis, trauma, infection and tumors
- Compression fractures affect 25% of postmenopausal women
- Only 33% of fx in elderly women are diagnosed; often misdiagnosed as "arthritis"
- Remember your RED FLAGS for this age group
- Typical presentation is an elderly female w/acute onset of mid back pain; this may be traumatic or non traumatic
- Dx is typically made by pain xray studies; other imaging studies may include MRI, CT, Bone Scan
38
Vertebral Compression Fx Tx
- Majority of mild to mod compression fx are treated w/immobilization in a brace or corset for 6-12 wks
- Surgery: balloon kyphoplasty or vertebroplasty (inject cement); surgical stabilization
39
Osteoporosis (AKA Metabolic Bone Disease)
- Compression fx: common cause of spine pain in the elderly, those w/malnutrition, on corticosteroids, EtOH abuse, smokers
- Sudden onset of spine pain w/o obvious trauma
- Usually w/muscle spasm
- Increased w/standing, walking, bending
- Often improved w/recumbence
- Takes at least 3 months to heal
40
Spine Tumors
- Primary bone tumors are uncommon; however, in 75% of cases, the vertebral body tumors are malignant (Multiple myeloma-MC; chordoma; osteosarcoma-very aggressive; hemangioma)
- Metastatic lesions: to and from lung, breast, and prostate are MC
- Radiographic imaging: Plain xrays, radionuclide bone scnas, MRI, CT guided bx for dx
- Determine if hot or cold (vascular or avascular)
41
Spinal Stenosis
- "choking"
- Spinal cord or spinal nerve roots are compressed, producing pain, tingling and weakness
- Radiates into the butt and down the leg
- Classically, worse w/standing and walking, relieved w/sitting and resting
- The grocery cart sign: leaning foreward
42
Spinal Stenosis Tx
- Avoid activities or motion that put the spine in extension
- NSAIDs or other oral analgesics
- Epidural steroid injections, no more than 3/yr
- PT should consist of exercises that emphasize "flexion" type exercises and pelvic tilts
- Surgical decompressoin of the stenotic neuroalignments (goal is to "take the pressure off the nerves")
- Fortunately, surgical intervention is successful and rewarding
43
Cervical Fx
- Fracture of one or more cervical vertebrae = broken neck
- Often involves muscle sprain, dislocation of the intervertebral discs and damage to the spinal cord
- This is a MEDICAL EMERGENCY: prompt evaluation and tx is essential
- Cervical spine injuries cause an estimated 6000 deaths and 5000 new cases of quadriplegia each year
44
Cervical Fx Tx
- Initially complete immobilization of the cervical spine
- Various forms of diagnostic imaging is warranted (xray, CT, MRI)
- Minor fractures may require simple soft collar bracing w/observation
- Severe fracture/dislocatoins may require halo traction and surgical stabilization
45
Cauda Equina Syndrome
- Occurs when there is severe compression on the cauda equina
- MEDICAL EMERGENCY requiring surgical decompression
- Failure to recognize=BAD, PERMANENT DEFICITS
- Innervates B&B: lifetime incontinence and sexual function compromised
46
Cauda Equina Causes
Tumors/Lesions
Trauma
Spinal Stenosis (Lumbar)
Inflammatory conditions
47
Cauda Equina Signs
- Multiple: depends on nerve roots affected
| - Weakness, saddle anesthesia, incontinence are common
48
Cauda Equina Tx:
- MEDICAL EMERGENCY
- Emergent spinal decompression
- If caused by trauma, immobilization as well
49
Scoliosis
- Curvature of the spine
- Affects 2-3% of the population, or an est 6 million americans
- Affects infants, adolescents and adults
- Priarmy age of onset is between 10-15
- 85% of cases are classified as idiopathic
- Dx made by H&P and plain xrays
- If underlying neurologic cause is suspected, MRI scan is warranted
- In the primary care setting, if adequate xrays are available, obtain full spine (PA and Lat) views and observe or refer to specialty clinic
50
Scoliosis Tx
General guidelines for tx include:
- Curves less than 20 degrees=observation
- Curves between 20-40 degrees=bracing
- Curves greater than 40 degrees=surgical correction
